May/June 2016
13
FEATURE
Health history
Look particularly for conditions that can contribute to hearing
loss and tinnitus, such as hypertension, hypothyroidism, diabetes
mellitus, arteriosclerosis, and autoimmune disorders (e.g., lupus
or rheumatoid arthritis). Also consider ototoxic medications, such
as aminoglycoside antibiotics, cisplatin, furosemide, valproic
acid, and high doses of quinine-containing compounds. When
possible, patients with hearing loss or tinnitus should be given
alternative medications with lower risks of ototoxicity. Excessive
use of alcohol, caffeine, and aspirin or other nonsteroidal anti-
inflammatory drugs can exacerbate tinnitus for some patients.
However, moderate use of these products is usually OK.
Tinnitus history
Determine the duration of tinnitus and whether circumstances
such as upper respiratory infection, otalgia, noise exposure, head
trauma, sudden hearing loss, or vertigo occurred at the time of
tinnitus onset. Ask the patient to describe the tinnitus: Is it inter-
mittent or constant? High- or low-pitched? Unilateral or bilateral?
Pulsatile or steady? Unilateral tinnitus and hearing loss provide
preliminary evidence for acoustic neuroma or cerebrovascular
accident. High-pitched tinnitus is usually associated with high-
frequency hearing loss caused by presbycusis (hearing impairment
due to aging) or excessive noise exposure. Low-pitched roaring
tinnitus is sometimes associated with low-frequency hearing loss
exhibited by patients with Meniere’s Disease. Pulsatile tinnitus,
especially if synchronous with the patient’s pulse, can indicate
vascular abnormalities. Ask the patient if fatigue, stress, noise
exposure, or any medications exacerbate the tinnitus. Also ask if
masking sounds (such as water running in the shower), medications,
or any other factors provide relief from tinnitus. This information
can be used to formulate a tinnitus management program. Assess
the severity of the patient’s tinnitus using an instrument such as
the Tinnitus Functional Index (TFI), a 25-item questionnaire that
allows the patient to rate the negative impact of tinnitus on daily
activities and enjoyment of life.
3
Higher scores on the TFI indicate
that patients perceive their tinnitus to be a significant, even debil-
itating problem. The TFI questionnaire can be obtained for no
cost here:
/
tinnitus-clinic/tinnitus-functional-index.cfm
Psychosocial history
Inquire about the patient’s marital and occupational status.
Unemployed patients living alone often perceive tinnitus to be
more severe than do employed patients who have supportive
social networks. Also ask about any history of insomnia, anxiety,
depression, obsessive-compulsive disorder, or psychosis. A ques-
tionnaire such as the Beck Depression Inventory can be used to
assess the presence and severity of depression. Many studies have
shown that tinnitus severity is positively correlated with insomnia
4
,
anxiety
5
, depression
6
and obsessive-compulsiveness
7
. Effective
treatment of these conditions can contribute to reductions in
tinnitus severity
8
.
Physical exams and testing
Patient evaluations should include the following physical exami-
nations and tests.
Otolaryngologic/head and neck exam.
Otoscopic examina-
tion can detect infections such as otitis media, which will usually
be accompanied by complaints of ear pain or fullness, and
possibly hearing loss in combination with tinnitus. Otoscopy can
also detect impacted earwax (cerumen), which can occlude the
ear canal or cause immobilization of the tympanic membrane,
resulting in conductive hearing loss, tinnitus, and a feeling of
fullness in the ear. Symptoms usually resolve when the earwax is
removed. If the tinnitus is synchronous with the patient’s pulse, it
suggests a vascular contribution for the symptom. Auscultation of
blood vessels in the neck can reveal venous hums or other types
of bruits audible to the patient. Venous hum can be diagnosed
by temporarily blocking blood flow through the jugular vein on
the side where tinnitus is perceived.
Neurologic exam.
A complete neurologic exam should include
the Romberg test, Dix-Hallpike maneuver (if the patient experi-
ences vertigo), gait testing, and cranial nerve function tests.
Audiologic testing.
Audiologic tests should include pure tone air
and bone conduction thresholds, speech discrimination testing,
tympanometry, and most comfortable loudness (MCL) and uncom-
fortable loudness level (UCL) tests. Tympanometry is used to assess
middle-ear function. Abnormal tympanograms and significant
differences between air and bone conduction thresholds can indi-
cate otitis media, otosclerosis, or cholesteatoma. MCL and UCL
tests are used to assess the dynamic range of patients’ hearing.
Patients with UCLs that are only 5 to 20 dBs above their MCLs
have a reduced dynamic range of hearing that can be caused by
recruitment or hyperacusis. The audiometer can also be used to
match the tinnitus for pitch and loudness and to test the effects
of masking sounds on the patient’s tinnitus.
Additional evaluations.
Results of patient examinations and history
collection might warrant additional evaluations. For example,
asymmetrical hearing loss (15 dB or greater asymmetry at 2 or
more consecutive test frequencies) and unilateral tinnitus can
indicate a retrocochlear lesion such as acoustic neuroma (also
known as vestibular schwannoma). One test for retrocochlear
pathology is the auditory brainstem response (ABR). In this test,
clicks are presented through earphones while scalp electrodes
record brain responses to the sounds. Abnormal ABR waveforms
can indicate retrocochlear lesion (such as acoustic neuroma) as
